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Ilija Mosscrop - The Palms South Beach, Inc.m MIAMI ~EACF~ ~~;~~"''y<fE/ City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 j LOBBYIST REGISTRATION FORM Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any city board or committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on such action, decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board or committee. The term specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. NAME OF LOBB (First) M ~SSC,1'~~ f1~[1~ G y © a +~ it 1~1 ~ Y~'c! ~ 3 Z5 M I Gmi I~~c~ ~L 5313~j BUSINESS NAME N D ADDRESS (Number and Street) (City) (State) (Zip Code) Q `~~ 1 L ~, TELEPHONE NUMBER: FAX NUMBER: ~ EMAIL: .Please notify this office if yo _- ur contact information changes.. addiress phone,; or a"-mail-address. L LOBBYIST RETAINED BY: ' the ~G I nl,~ ~o.N- ~, ~3~e~ c~, sic NAME OF PRINCIPAL/CLIENT: ha! ~ ~ ~0~5 COI Iin G~ ' ICI iGnn i I y-O BUSINESS NAMED ADDRESS ~=1 • , (Nu ber and Street) (City) ~ ~ 5 O~ _ ~3 ~ (State) (Zip Code) TELEPHONE NUMBER:. FAX NUMBER: (Optional) EMAIL: (Optional) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: u SPECIFIC.LOBBY ISSUE:; ~ i o Z Issue to be lobbied (Describe in detail): _. nl. C1TY AGENCIES/INDIVIDUALS TO BE LOBBIED;: Pursuant to City Code Section 2-482(g) include _ _. _ . _ __ a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an appearance of an impropriety with any City personnel sought to be lobbied -- further, pursuant to, City Code Section 2-. 482(a)(4) include a statement of any contractual relationship (paid or unpaid)- from 12 months preceding said City personnel' commencement of service with the City to the present date, stating the general nature of the subject contractual relation. A Full Name of Individual Title B} Any Financial, Familial or Professional Relationshi ~ . .~ ~ f 9 4 P ~~~v~~ ~ ~~ ~~ ~::::~ i ~~ I •• ~T ~..~ `S I I. I V ~ .~ , r :' 1 ' E _~ ~' a ~,: ~ f, IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A} LOBBYIST DISCLOSURE: (Required} ~ So ~ B} PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPF~S T QQN) (Required). ~ ~l7 ~ `oo The .following information must be answered: ~, 1) Pursuant to Miami Beach City Code Section 2-488' Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": 0 Yes. ~No: Are you lobbying on a present or pending bid for goods equipment or services or on a present or pending award for goods eauipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited. Campaign Contributions By Lobbyists On Real Estate Development Issues": Yes ~ No: Are you lobbvina'on a pending application for a Development Agreement with the City or a4~cation for chance of zoning map designation or change to the City's Future Land Use MaD? 3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of "lobbyist" as .set forth in Section 2-481 above) .who .only appears as a representative of a not-for-profit corporation or entity without special compensation or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any item; shall register with'the .clerk as required by this section but, shall not be required to pay any registration fees. ^ Yes ^INo: Are you representing snot-for-profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER BATH: sr +nF Feral v~ ---- -- - - - - •v~~ vv nn~V ~ flG RCrVR 1 IIYV PERIOD. '_ ~' Signature of Lob yist I do solemnly swear that all of the foregoing facts are true and. co ect and than f have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all rep sting requirements. Signature of Lobbyist: - L,. Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: NCIPA! IDENTIFICATION: ^ Produced ID ^ Produced ID Form of Identification Form of Identification lm Personal) know L ~ ~`Y °~e Notary Public State of ± ;orida Y (~(JmGt) ivatary Public St:~te oY Fforid soppily known (Princip s° ~~ Alma P Cue Alma: P Cue ~ ~ ea My Commission DD757038 VII. SIGNATURE A PaO~ I ~ora~ .Expires 02110!2012 ~'Tr~~~r. x;]757038 o- Expires 02/10/201 ~ - State of Florida, County f Florida, County of Miami-Dade ~ ; 4\~ Sworn to and subscribed before me Swom and subscribed before me ,~~ _ .~= This 10 y h,(, 2010 This ~,~daY , 2010 ~ '"" -- r Signature o Publi Notary -State of Florida Signature of ublic tary - State of Florida - Notarizatio of Lo bvist's signature. Notarization f Prin iual's signature ~. TO BE COMPLETED B C ERK'S STAFF ~ Annual Registration fee. j Yes [ j No Amount P $ MCR # I Date Paid Lobbyist R®glstratton Form received and verified by ~ F:\CLER\SA~I\aFORMS\LOBBYIST FURMS\lobbyist R ~ Revised Q5/ /2010 i i .t t~~~~ City of Miami Beaeh, 1.700 Convention Center Drive, Miami Beach, Florida 33139, www.miomibeoch#Lgov CITY CLERK Office. CityClerkf~3miomibeachA.gov Tei: 305..673.7411 ,Fox: 305.673.7254 Acknowledgement of fines/suspension- from lobbying for foilure to comply with City of Miami Beceeh lobbying L¢>>ws LOBBYIST NAME: ~ t, ~ J A ~"~ D S~ G R-~ P I understand thot no later than Cktober 1st of e-otch veer, lobbyists subject to .lobbyist registration requirements shall submit to the city clerk ai signed sto~tement under oath listing all lobbying expenditures, as well as compensation received, for the preceding calendar year with regard to the. specific. issue on which the lobbyist ,has been engaged to lobby.. A statement shall be filed even if there have been ~o expenditures or compensation during the reporting period. The statement -shall (~st, in detail, each expenditure by category, including food and beverage, entertainment, research, .communication, media advertising, publications, travel, lodging and special events. I FAILURE TC~ TIMELY FILE THE EXPENDITURE AND FEE DISCLCISURE REPCIRT WILL RESULT IN A FINE OF .$50.00 PER DAY. ANY LOBBYIST 111/110 FAILS TO FILE THE REQUIRED EXPENDITURE REPORT BY DECEMBER 1, SHALL AUTOAAd~TICALLY BE SUSPENDED FROM LOBBYING UNTI~ ALL FINES 14RE PAID, UNLESS THE- FINE HAS BEEN APPEALED TO THE MIAMI-DADE COUNTY COMMISSION ON ETHICS AND PUBLIC TRUST. In the event alobbyist -fails to either file the report and/or pay the assessed fines,; the Clerk shall notify the Miami-Dade County Commission on Ethics and Public Trust. IN ADDITICIN, ONCE AN ISSUE 1 HAVE REGISTERED TO LCIBBY ON -HAS BEEN RESOLVED, I AIVI REQUIRED TO IMMEDIATELY NOTIFY THE CITY CLERK'S OFFICE OF L®BBYIST WITHDRAWAL IN WRITING. Signature: ~t-°1•~ Date: